GW1--03723_Well Construction - GW1_20230602

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WELL CONSTRUCTION RECORD
GW-1 For Into Uae On y:
1.WeU Contractor furor, don: la: .AT R. $
m FROM TO DESCRIPTION
ft.
Well Contractor Name ft.
for•m �eaaed ivi lla R'ua cable
C 0 DIAMETER TBICf4fpa8 MATE
NC Well Contractor CortiBeation N bar To
d' �12.. G t�toM, ft. ft• �.JaL.S h'' $l�fZ�t �
4 .0 It90 t ermal'•9 oa d-loo TE�
I U qER T=mcI0YE89
Company Name �r'r� 1�ail FROM To
I ff. ft'
Z,Well Construe Permit#: ft.
b,
2 all l COPPonror Nell oonstruclron permits UIC,County,Stare,Variance,era j
3.Well Use(check well use): 1'" N DIAMETER sLOT IZE T111 a MATERIAL
FROM TO
W r Supply Well; ft. rt fa
Agricultural �MunicipallPirblic ft.
Geothermal(Heating/Cooling Supply) OP-0 idendal Water Supply(single) ft.
Realdential Water Supply(shared) ig, _ •UT MA EMPLACEMENT METHOD&AMOUNT
IndustriaUCommoroial FROM To
kd stion O G ft.
Non-Water Supply Well: ft.
Recove ft.
•Monitoring tt.
In ec on ell: E3Groundwater Romedlation YEI:pp 1C to Ii a la• EMPLACEMENT METHOD
• .19.SA � M^TEw'u'
Aquifer Recharge Salinity Barrier FROM TO
Aquifer Storage and Recovery �.`..` fL ft.
Aquifer Test ti;`�`,'�. .0Storinwator Drainage ft ft.
"V..! [3SubsidenceControl
Experimental Technology` fi'I 20.0 LIN OG' Hadif "v-grR1PTIONacolor beerdoess aoWrock sin era
Geothermal(Closed Loop) E)Tfacer FROM TO
Geothermal Heatin Coolln Return .Other ex lain under 921 Remarks fL ft. 'i
g
Completed.'- LL .3 WeU Imft fa ft. '
4.Date Wells ') - —.Y� ;-•,e..,;�
5a,Well Locution:
ft. . _..
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fE IDN(ifapp8cable) �
Facility/Owner Name �+ i y fL ft' ri
r
ii
Physice�dross, Ity,and Zip 2f. ARKS
Parcel Identi8oationNo.(PIN)
Cowry
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22,Certification: �.
(if wall field,one latllong is sufficient) ! W � s �
;- �L N Data
Signatum of CerdBed Wa8 Contractor
()�rmauent or Temporary By slg+tins this form,I hereby cerlljy that the weN(sJ was(were)constructed!n accordance
6.Is(are)the well s
No with I SA NCAC 02C.0100 orl �o the all or0,me�e/!Corun•ucrlon Standards and that c
Well: Yes ar With
y ojthLs record has been Provided
7.is this a repair to an exlsttug pp p
if this Is a report,JI►I out known well construction lryformalion nd explain the no
of 23.Site diagram or addlHoual well details:
You may use the beak of this page to provide additional wall alto details or wel
-repair under f121 remarks seclton or on the back ojrhls jomr,
You may also attach additional pages if necessary.
robe/DPT or CiOaed-Irbop;Geothermal Wells having fw8U=0 construction details.
8.For Geog 1 OW-1 is needed,'indicata TOTAL NUN®
BR construction,only
_(fL) 24a.Fnr A i Wel1S: Submit this form within 30 days of completion of we
9,Total well depth below land surface: o0"and 2®1001 construction to the following:
For multiple wells list all depths Ud pferenf(e)ample-3@7 O
(fL) Division of Water Resources,information
27699 16]7 Unit,
10.Static water level below top of ceslugt•' Processiu
1617 Mail Service Center,Raleigh,
l f water level Is above casing use'+" � 24b.
r slon Wells: in addition to sending the form to the address in 2
Il.Borehole diameter: —( ') above,also aubmlt one copy of this form within 30 days of completion of w
owing:
12.WeU construction methods construction to the foll
auger,rotary,cable,direct push.etc,) Division 1636 MooeService�Contor�Raleigh,NC 276991636
ater
('r Program,
.e.
y in addition to sending the form
FOR WATER SUPPLY WELLS ONLY: v . >+uuDiv&Intecdon��§r
/ji_I yl 24c. of this form wig 30 Sys
Metbod of test:_--s— the addresses) above, also submit one copy health department of the cou
138.Yield(gpm) completion of well construction to the county
p Amount: where conanticted.
13b.Disinfection type: G Revised 2•22.7
out of Environmental Quality.Division of Water Resources
North Caroline DePartm
Form OW-1 J